CMS (Medicare), Patient Driven Payment Model PDPM Presented by: Cindy Gensamer, MBA, HSE, LNHA Vice President Absolute Rehabilitation
What is it? PDPM Released in Final Rule 7-31-18 Effective 10-1-19 Patient Driven Payment Model New payment model by CMS Replaces the RUG system Assigns every patient to a classification to determine daily payment rate 6 Components (5 adjusted with casemix, 1 noncasemix component)
RUGS compared to PDPM RUGS 2 casemix components Index maximizing (selects highest) 5 scheduled assessments Constant payment for LOS Therapy delivery to determine payment Concurrent/Group therapy deterred PDPM 5 casemix components Index combining 1 scheduled assessment Payment reduction over LOS Therapy delivery will not determine payment Concurrent/Group therapy permitted max is 25% combined
PDPM Casemix Components Therapy Physical Therapy Occupational Therapy Speech Therapy Nursing Nursing Non-Therapy Ancillary
Differences RUGS Care is paid for at the highest casemix index (RUG that the patient falls into) 66 RUG groupers 23 Therapy RUG groupers PDPM Grouper will identify all 5 components and payment will be based on a per diem rate.
PT & OT Component for Casemix Two Parts for Each Resident Clinical Category (reason for skilled stay) Functional Status from GG
PT/OT Categories were reduced to 4 categories
CMS-1696-F Page 126 PDPM would use ICD-10-CM diagnosis codes entered in the first line of section I8000 on the MDS assessment to assign residents to clinical categories for classification and payment purposes in three PDPM payment components (PT,OT,SLP)."
Functional Scores from GG PT & OT Component
Functional Status from GG
PT & OT Component add clinical/function 16 casemix classifications
SLP Case Mix Clinical Categories Acute Neurologic Non Neurologic Presence of: Swallowing Disorder (K0100Z) Mechanical Diet (K05110C2) Presence of: SLP related comorbidity Mild to severe cognitive impairment
SLP Related Comorbidities
12 SLP Case Mix Groups
Nursing Component Reduced to 25 nursing RUGs ADL Score based on Section GG of the MDS
Nursing Component Section GG items
Nursing Component Scoring Section GG Items
25 Nursing Categories
Non-Therapy Ancillary Component
NTA Case Mix Scores
Payment Variable Length of Stay PT & OT Component
Payment Variable Length of Stay NTA Component
Assessments Required in PDPM
MDS Scheduling Reduced Assessment Schedule 5-day assessment Will establish the payment category for entire Medicare stay Grace days included in Interim Payment Assessment (IPA) Will be used to capture significant changes in resident condition during the stay Not anticipated to return to his/her prior clinical status within 14 days Criteria Classification and Payment change Required and if missed will be billed at default rate Discharge assessment Items will be added to Discharge assessment to capture the total amount of therapy provided during Medicare stay
D/C Assessment Changes Adding Therapy Minutes
Therapy Delivery Modes Group/Concurrent combined may be up to 25% of minutes delivered Discipline specific Total amount of therapy over entire stay
Return to Provider RTP When a claim is submitted, it processes through a series of edits in the Fiscal Intermediary Standard System (FISS), to ensure the information submitted is complete and correct. If the claim has incomplete, incorrect or missing information, it will be sent to your return to provider (RTP). This is found in the DX to Clinical Category mapping table.
Example of Management of Therapy under PDPM Patient Driven Payment Model Treatment 5 times a week Urban Model PT $59.33 OT $55.23 ST $22.15 PT Grouper Weight Rate Minutes OT Grouper Weight Rate Minutes ST Grouper Weight Rate Minutes TA 1.53 $ 90.78 45 TA 1.49 $ 82.30 45 SA 0.68 $ 15.07 0 TB 1.69 $ 100.27 45 TB 1.63 $ 90.03 45 SB 1.82 $ 40.32 up to 30 TC 1.88 $ 111.54 60 TC 1.68 $ 92.79 45 SC 2.66 $ 58.92 up to 30 TD 1.92 $ 113.92 60 TD 1.53 $ 84.51 45 SD 1.46 $ 32.34 0 TE 1.42 $ 84.25 50 TE 1.41 $ 77.88 45 SE 2.33 $ 51.61 up to 30 TF 1.61 $ 95.53 50 TF 1.59 $ 87.82 45 SF 2.97 $ 65.79 up to 30 TG 1.67 $ 99.09 50 TG 1.64 $ 90.58 45 SG 2.04 $ 45.19 up to 30 TH 1.16 $ 68.83 45 TH 1.15 $ 63.52 45 SH 2.85 $ 63.13 up to 30 TI 1.13 $ 67.05 30 TI 1.13 $ 62.41 30 SI 3.51 $ 77.75 up to 45 TJ 1.42 $ 84.25 45 TJ 1.42 $ 78.43 30 SJ 2.98 $ 66.01 up to 45 TK 1.52 $ 90.19 45 TK 1.54 $ 85.06 30 SK 3.69 $ 81.74 up to 45 TL 1.09 $ 64.67 30 TL 1.11 $ 61.31 30 SL 4.19 $ 92.81 up to 45 TM 1.27 $ 75.35 45 TM 1.3 $ 71.80 30 TN 1.48 $ 87.81 60 TN 1.49 $ 82.30 45 TO 1.55 $ 91.97 60 TO 1.55 $ 85.61 45 TP 1.08 $ 64.08 30 TP 1.09 $ 60.20 30
Example Mr. Clean Mrs. Butterworth
No worries, we got this!
Questions? Headline Cindy Gensamer, LNHA, MBA Vice President Absolute Rehabilitation & Consulting 339 East Maple St. North Canton, Ohio 44720 330-498-8204 cgensamer@abstherapy.com